Adolescent Suicide in Appalachia and Rural Areas

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Adolescent Suicide in Appalachia and Rural Areas

• Robert M. Bossarte, Ph.D.
• Department of Community Medicine
• Injury Control Research Center
• rbossarte_at_hsc.wvu.edu

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Overview

• Review prevalence of suicide
• Adolescent suicide
• Risk and protective factors for suicide
• Socio-ecological model
• Suicide in rural areas
• What makes rural areas unique
• Economic and social conditions in Appalachia
• Theoretical models of integration and community
• Models of healthcare utilization
• Putting it all together

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Considerations

• Simultaneous consideration of individual and
  contextual characteristics
• 10-24 age group(s) (10-14, 15-19, 20-24)
• Time of social and psychological change
• General decline in deaths from suicide
• Reports of an increase in suicide rates among
  residents of rural areas
• Source Singh Siapush, 2002

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Suicide in the United States

• In 2004 there were 32,439 deaths by suicide in
  the U.S. (age-adjusted rate 10.92/100,000)
• Suicide is the eighth leading cause of death for
  U.S. men of all ages
• Suicide rates are highest among Whites and second
  highest among American Indian and Native Alaskan
  men
• Of the 25,555 suicide deaths reported among men
  in 2004, 59 involved the use of a firearm
• Women report attempting suicide during their
  lifetime about three times as often as men
• Source CDC

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Risk Factors

• Previous suicide attempt(s)
• History of mental disorders
• History of alcohol and substance abuse
• Family or peer history of suicide
• History of child maltreatment
• Feelings of hopelessness
• Impulsive or aggressive tendencies
• Barriers to accessing mental health treatment
• Physical illness
• Easy access to lethal methods
• Unwillingness to seek help
• Isolation, a feeling of being cut off from other
  people
• Source CDC Suicide Fact Sheet

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Protective Factors

• Effective clinical care for mental, physical, and
  substance abuse disorders
• Easy access to a variety of clinical
  interventions and support for help seeking
• Family and community support
• Support from ongoing medical and mental health
  care relationships
• Skills in problem solving, conflict resolution,
  and nonviolent handling of disputes
• Cultural and religious beliefs that discourage
  suicide and support self-preservation instincts
• Source CDC Suicide Fact Sheet

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Suicide in West Virginia

• IN 2004, WEST VIRGINIA HAD THE 10TH HIGHEST
  SUICIDE RATE IN THE UNITED STATES (all ages)
• (age-adjusted rate 15.29/100,000)
• 2003 11th (14.00/100,000)
• 2002 10th (14.79/100,000)
• 2001 9th (15.40/100,000)
• 2000 12th (13.12/100,000)

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States with Suicide Rates Higher than West
Virginia

• Alaska (23.37/100,000)
• Nevada (19.24/100,000)
• New Mexico (18.73/100,000)
• Montana (18.52/100,000)
• Wyoming (17.62/100,00)
• Idaho (17.45/100,000)
• Colorado (17.21/100,000)
• Utah (17.08/100,000)
• Arizona (15.72/100,000)
• Lowest - New York (5.99/100,000)

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Suicide in WV, 1995-2004
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Adolescent Suicide

• Suicide is the 3rd leading cause of death among
  adolescents and young adults age 10-24
• In 2004, there were 4,599 deaths from suicide
  among members of this age group
• (age-adjusted rate 7.18 per 100,000)
• In that same year there were an estimated 160,868
  self-inflicted injuries treated in US emergency
  departments among persons
• (age-adjusted rate 255.31 per 100,000)
• Males accounted for 82.3 of all suicides
• Source Centers for Disease Control and
  Prevention - WISQARS

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Top 5 Leading Causes of Death, 2004
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Percentage of High School Students Who Seriously
Considered Attempting Suicide, 1991 2005
During the 12 months preceding the survey 1
Significant linear decrease and quadratic change,
P lt .05
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Among Adolescents and Young Adults

• The overall rate of suicide among youth has
  declined steadily since 1992
• Recent reports have suggested the decline has
  slowed
• American Indian and Alaskan Natives have the
  highest rate of suicide in the 15 to 24 age group
• In 2004, firearms were used in 51 of youth
  suicides (10-24)
• Recent data indicate an increase in the number of
  firearm related suicides among youth age 10-19
  years
• Source CDC Suicide Fact Sheet Mortality Reports

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Developmental Considerations

• Ages 11-21 include two developmental periods
• adolescence
• young adulthood
• Ties to parents diminish with the emergence of
  dominant peer relationships
• Marked by instability (ex. residential mobility)
• Suicide among adolescents often occurs in the
  context of developmental failures in social and
  economic contexts
• failure to graduate from high school
• Failure to find employment
• unsuccessful dating relationships
• Source Conner Goldston, 2007

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Violence and Suicidal Behavior

• Youth who have attacked others with a weapon,
  engaged in dating violence, or perpetrated sexual
  violence have been shown to be at higher risk for
  suicidal behavior
• Adolescents who report suicidal behavior are more
  likely to also report involvement in physical
  fighting
• Adolescents who report early substance use are
  more likely to report suicide attempts
• Sources Evans et al., 2001 Borowsky et al.,
  1997 Swahn et al., 2004

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Interrelationships among Onset of Violent
Behaviors
Peer Violence
Suicidal Behavior
Child Maltreatment physical, sexual, emotional,
neglect
Intimate Partner Violence
Dating Violence
Sexual Violence
CHILDHOOD
ADOLESCENCE
ADULTHOOD
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Socio-Ecological Model

• The socio-ecological model considers the
  interaction between individuals and their family,
  peer, school, and community environments
• The Socio-Ecological Model (SEM) has been
  described as an onion, with one level wrapping
  around another
• At the center of the model is the individual
• At the individual level, the behaviors,
  knowledge, attitudes, beliefs, and skills are
  considered
• However, the model recognizes that many external
  forces also influence individual behaviors and
  characteristics

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Socio-Ecological Model
Individual
Family
Peers
School
Community
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Health and Place in Rural Areas

• How do characteristics of rural areas influence
  individual behaviors?
• What are the qualities unique to rural areas that
  are associated with higher rates of suicide?
• Using the socio-ecological model, considerations
  of suicide should consider community, academic,
  peer, and family contexts

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Rural Areas and Risk for Suicide

• Suicide rates in rural areas have been associated
  with
• Lower population density
• Social and geographic isolation
• Poor economic conditions (agricultural work,
  unemployment)
• Individualism
• Religiosity
• Stigma associated with mental disorders
• Low rates of mental health service utilization
• Availability of firearms
• Availability of other lethal means (poisoning)
• Source Hirsch, 2006

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Economic Conditions in Appalachia
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Population Density in Appalachia
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Educational Attainment in Appalachia
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Suicide in Appalachia

• Risk factors associated with residence in rural
  Appalachia
• Low population density
• Social and geographic isolation
• Low educational attainment
• Poor economic conditions
• Strong religious base
• Culture of individualism
• Availability of firearms?
• Low rates of mental health service utilization?
• High rates of interpersonal violence?
• Substance use?

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Social Structure and Suicide

• Integration with others has long been thought to
  be protective against risk for suicide
• Integration and meaningful interaction with
  others has been conceptualized as social capital
  and/or collective efficacy
• Social capital is a measure of community
  integration, exchange, and trust
• Collective efficacy is a measure of a communitys
  ability to maintain social control
• Communities low in social capital/collective
  efficacy have been associated with higher rates
  of violent crime
• Source Putnam, 2000 Sampson, Raudenbush,
  Earls, 1997

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Area Characteristics Associated with Low Social
Capital/Collective Efficacy

• Low levels of Social Capital/Collective Efficacy
  have been associated with
• Population migration
• Concentrated poverty
• Few community organizations
• Immigrant concentrations
• Greater numbers of single-parent households
• Low levels of civic involvement
• Low levels of home ownership

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Why Worry about Social Structure?

• Socio-Ecological Model
• Stigma
• Individualism
• Isolation
• Integration with Others
• Burdensomeness
• Service Utilization
• Source Joiner, 2004

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Andersen-Newman Model of Health Service
Utilization

• Access and use of health services is thought to
  be a product of three sets of characteristics
• Predisposing Characteristics
• Enabling Characteristics
• Need Characteristics
• Source Andersen Newman, 1975

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Predisposing Characteristics

• Predisposing characteristics include
• Social Capital
• Ethnicity
• Age
• Gender
• Socioeconomic status
• Education
• Health status

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Andersen-Newman Model
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Question (1)

• What processes/characteristics unique to rural
  areas are also associated with an increased risk
  for suicide?

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Summary

• Suicide is a multifaceted individual behavior
  comprised of
• Biochemical processes
• Medical conditions
• Psychosocial traits
• Social relationships
• Community characteristics

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Summary (2)

• Appalachia is a region characterized by
• Low population density
• Low educational attainment
• Poverty
• Occupational homogeneity
• Migration
• Low economic growth
• RESULT?

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Question (2)

• How can suicide prevention programs use
  information about characteristics of rural areas
  to reduce risk for suicide?

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Direction

• Link between social capital and health service
  utilization may partially explain lower use of
  mental health services in rural areas
• Identify modifiable area level characteristics
  associated with social capital and suicidal
  behaviors
• Urban/rural differences

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Questions?
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Thank You